Primary Focus: Covered Benefits Title/Description: Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Act Citation: D.C. Code §§ 31-3101 – 31-3112 Summary: Under the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Act, individual and group health plans must provide coverage for medical and psychological treatment of drug abuse, alcohol abuse, and mental illness. Covered benefits for drug abuse, alcohol abuse, and mental illness in insurance policies is limited to inpatient, residential, and outpatient services certified as necessary by a physician, psychologist, advanced practice registered nurse, or social worker. The Act further provides for guidelines in determining reimbursement rates and states that charges for coverage of behavioral health services shall not be excessive and must be reasonably related to the cost of providing coverage based on a series of factors. The guidelines set out in the act are not applicable to the District of Columbia Alliance Program, Medicaid Program, and Post-1987 District of Columbia Employees’ Health Insurance Benefits Plan. D.C. Code § 31-3105 mandates that methods for determining payment or reimbursement for mental health and substance abuse treatment services be consistent with those for physical illnesses in general. Methods for determining reimbursement rates shall take into consideration usual, customary, and reasonable charges for mental health services. Under D.C. code, deductibles and copayments can be applied. For individual and small group plans, inpatient and outpatient benefits set forth in D.C. Code § 31-3104 must have a lifetime payment limit of not less than $80,000 or one third of the lifetime maximum for physical illness. For large group plans, the inpatient and outpatient benefits set forth in D.C. Code § 31-3104 must be applied with the same lifetime limit and annual limits for medical, surgical and mental health benefits.
Group health plans can be exempt from complying with these mental health benefits provision if the cost of compliance for large group markets results in at least a 1% increase in the cost of the plan. Health maintenance organizations are held to the same mandatory coverage benefits as health insurers under the statute. Effective Date: Public law last approved May 5, 2017. Current through July 27, 2018. Notes: 2015 D.C. Law 20-265, § 102, 62 DCR 1529.
Primary Focus: Program Oversight Title/Description: Behavioral Health Ombudsman Program Citation: D.C. Code § 7-1131.19 Summary: D.C. Code § 7-1131.19 established a behavioral health ombudsman to provide residents of D.C. with assistance in accessing behavioral health services. The ombudsman shall assist consumers in resolving problems concerning behavioral health providers, behavioral health facilities, and access to behavioral health care services and programs by referring consumers to appropriate regulatory agencies, guiding consumers through existing complaint processes, and assisting consumers in informally resolving problems through discussions with their providers. In addition, the ombudsman shall educate residents about behavioral health coverage, refer individuals to services, and create strategies and suggestions for improving access to quality mental health care. Effective Date: June 7, 2012. Notes: Amended by 2012 D.C. Law 19-141, § 402(b), 59 DCR 3083.
Primary Focus: Covered Benefits Title/Description: Health Benefit Plan Certification Citation: D.C. Code § 31-3171.09 Summary: D.C. Code § 31-3171.09 requires health benefit plans to comply with the Mental Health Parity and Addiction Equity Act of 2008 in order to be certified as qualified health plans. Health plans must cover behavioral health and outpatient services for mental health and substance use disorders without day or visit limitations. In addition, the D.C. Code states that for the purposes of the essential health benefits benchmark plan, health plans must include applied behavioral analysis for the treatment of autism spectrum disorder. Effective Date: March 2, 2012 Notes: Enacted by 2012 D.C. Law 19-94, § 10, 59 DCR 213
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